Provider Demographics
NPI:1508369737
Name:HEARNE, RUSSELL WARREN (PT,DPT)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WARREN
Last Name:HEARNE
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 CAMPFIRE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611
Mailing Address - Country:US
Mailing Address - Phone:936-465-6282
Mailing Address - Fax:
Practice Address - Street 1:192 HIGHWAY 3226
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-8915
Practice Address - Country:US
Practice Address - Phone:936-465-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09007R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist